2. A nurse asks a patient to describe his new onset of leg pain. He slept well through the night, but this morning he suddenly developed pain in his left lower leg that is red and too painful to touch. Nothing relieves the pain. Based on these data, the nurse suspects which disorder is causing this pain?
a. Rheumatoid arthritis
b. Osteoarthritis
c. Gout
d. Tendonitis
ANS: C

3. During a history, the patient reports having gout. Based on this information, what findings does the nurse anticipate during a focused assessment?
a. Warm, tender, and deformed wrists and peripheral interphalangeal (PIP) joints bilaterally
b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes
c. Enlarged and tender PIP or distal interphalangeal (DIP) joints on one or several fingers
d. Tenderness with pronation and supination of the elbow and point tenderness on the lateral epicondyle
ANS: B

Feedback
A This is a description of findings of a patient who has rheumatoid arthritis. Bilateral joint involvement is common.
B This is a description of gout. The pealike nodules are tophi, collections of uric acid in subcutaneous tissue.
C This is a description of findings of a patient who has osteoarthritis. Enlarged and tender PIP joints refer to Heberden nodes and DIP joints refer to Bouchard nodes.
D This is a description of epicondylitis (tennis elbow).
DIF: Cognitive Level: Apply REF: 301| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

4. A patient reports joint pain interfering with sleep and morning joint stiffness for the first hour after getting out of bed. Considering this report, what abnormal findings does the nurse anticipate during the examination?
a. Abrupt onset of local tenderness, edema, and decreased range of motion of the shoulder and hip bilaterally
b. Decreased range of motion of one hip and knee with pain on flexion and crepitus during movement of these joints
c. Erythema in one great toe, ankle, and lower leg that is painful to the touch
d. Hot, painful, deformed, and edematous wrists and peripheral interphalangeal joints bilaterally
ANS: D

Feedback
A This examination finding is more consistent with bursitis.
B This examination finding is more consistent with osteoarthritis.
C This examination finding is more consistent with gout.
D The history and these examination findings are consistent with rheumatoid arthritis. Joints are involved bilaterally in rheumatoid arthritis because it is a systemic autoimmune disorder.
DIF: Cognitive Level: Analyze REF: 301| 318| 332
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

5. In assessing a patient with a history of poliomyelitis, the nurse suspects the right leg muscles are smaller than the left leg. What is the best approach for the nurse to confirm or reject this suspicion?
a. Palpating both legs using the pads of the thumb and index fingers and comparing one side with another
b. Using a tape to measure each legs circumference at the same location, above or below the nearest joint
c. Using a goniometer to measure the upper and lower legs with the patient in supine and standing positions
d. Palpating the legs using the tips of the thumb and index fingers, and comparing the findings with the Lovett scale
ANS: B

Feedback
A This describes an appropriate procedure to determine tenderness of muscles, but not muscle size.
B This technique is correct, provides a baseline for future comparisons, and provides measurements for side-to-side comparisons.
C The goniometer is used to measure the degree of joint flexion and extension rather than muscle size.
D The Lovett scale is used to grade and record muscle strength, rather than muscle size.
DIF: Cognitive Level: Apply REF: 304
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific Assessments

6. In assessing the joint range of motion of a patients knees, the nurse notices the flexion is less than expected in both knees. What is the next appropriate action for the nurse?
a. Documenting this finding as expected for this patient because it occurs in both knees
b. Palpating the suprapatellar pouch on each side of the quadriceps for contour, tenderness, and edema
c. Using a goniometer to measure the flexion in both knees and comparing the results with expected flexion
d. Applying opposing force to the lower leg while the patient tries to maintain flexion and extension
ANS: C

Feedback
A This is not an expected finding. Even when the finding is bilateral, when it is abnormal, additional examination is needed.
B This is the procedure for palpating the knees, in which data are collected, but it may not have a direct bearing on the lack of flexion of the knees.
C When a joint seems to have increased or decreased range of motion, use a goniometer to measure the angle.
D This is the procedure for testing leg muscles for strength, in which data are collected, but it may not have a direct bearing on the lack of flexion of the knees.
DIF: Cognitive Level: Apply REF: 307
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific Assessments

7. The nurse asks the patient to hold the arms straight out, perpendicular to the floor, and the nurse tries to push the patients arms down. This procedure tests the strength of which muscles?
a. Triceps
b. Biceps
c. Trapezius
d. Deltoid
ANS: D

Feedback
A The nurse would test the triceps muscle strength by having the patient extend the arm and resist while the nurse tries to push the arm to a flexed position.
B The nurse would test the muscle strength of the biceps by having the patient flex the forearm while the nurse applies resistance.
C The nurse would test the trapezius by having the patient shrug the shoulders against resistance.
D The patient uses the deltoid muscles to resist the action of the nurse.
DIF: Cognitive Level: Apply REF: 308| 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

8. To assess the triceps and biceps muscle strength, the nurse applies resistance to the patients arm. What should be done to ensure the appropriate muscle is being assessed?
a. The patient pushes up against the nurses hand to abduct the triceps muscle and pushes down against the nurses hand to adduct the biceps muscle.
b. The patient pushes forward against the nurses hand to extend the triceps muscle and pulls backward against the nurses hand to flex the biceps muscle.
c. The patient pulls backward against the nurses hand to flex the triceps muscle and pushes forward against the nurses hand to extend the biceps muscle.
d. The patient pushes up against the nurses hand to abduct the biceps muscle and pushes down against the nurses hand to adduct the triceps muscle.
ANS: B

Feedback
A Abducting and adducting test range of motion rather than muscle strength.
B This is the correct technique for assessing these muscles.
C This is a reversal of the correct technique.
D Abducting and adducting test range of motion rather than muscle strength.
DIF: Cognitive Level: Apply REF: 308| 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

9. The nurse notes that there is an audible clicking sound when the patient opens and closes the mouth. What is the appropriate response of the nurse at this time?
a. Recording this as an abnormal finding, requiring additional assessment
b. Measuring the distance between each side of the mandible and the eyes
c. Applying resistance to the maxilla and asking the patient to repeat the motion
d. Documenting this finding as expected if no other signs or symptoms are found
ANS: D

Feedback
A This would be an incorrect action because clicking of the mandible with no other associated signs or symptoms is a normal finding.
B This is not a correct assessment technique to use.
C This is not a correct assessment technique to use.
D The mandible should move smoothly and painlessly. An audible or palpable snapping or clicking in the absence of other symptoms is not unusual.
DIF: Cognitive Level: Apply REF: 309-310
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific Assessments

10. A nurse palpates the patients jaw movement by placing two fingers in front of each ear and asking the patient to slowly open and close the mouth. What movement does the nurse ask the patient to do next?
a. Move the jaw side to side.
b. Swallow.
c. Smile.
d. Clench the teeth together.
ANS: A

11. When assessing the neck of a healthy adult, a nurse expects which findings?
a. A convex contour of the posterior cervical spine
b. Bending of the head to the right and left (ear to shoulder) 15 degrees
c. Turning the chin to the right shoulder and then the left shoulder
d. Hyperextension of the head 30 degrees from midline
ANS: C

Feedback
A The posterior cervical spine should be concave.
B The patient should be able to laterally bend the head 40 degrees from midline in each direction.
C This is an expected finding.
D The patient should be able to hyperextend the head 55 degrees from midline.
DIF: Cognitive Level: Understand REF: 310-311
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: System Specific Assessments

12. A patient asks, Why is touching my toes necessary? This is a sports physical examination, not exercise class. What is the most appropriate response by the nurse?
a. This is the best way to check for symmetry of your arms.
b. I am looking at the stretch of your ham strings.
c. This allows me to see how straight your spinal column is.
d. I am assessing the flexion of your spine.
ANS: C

Feedback
A This is an incorrect technique for assessing arm symmetry.
B The hamstrings are not normally assessed.
C This is the correct technique for inspecting the spine and for detecting scoliosis.
D This is not a correct statement.
DIF: Cognitive Level: Apply REF: 312-313
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation

13. How does a nurse document the finding from the patient shown below?

a. Kyphosis
b. Lordosis
c. Osteoporosis
d. Scoliosis
ANS: D

Feedback
A Kyphosis is a posterior curvature (convexity) of the thoracic spine.
B Lordosis is an anterior curvature (concavity) of the spine.
C Osteoporosis occurs when the bones become porous and fracture easily.
D Deviation of the spine or asymmetry of shoulder or iliac height is an abnormal finding. This figure shows a patient who has scoliosis, a lateral curvature of the spine.
DIF: Cognitive Level: Understand REF: 312-313
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

14. A patient reports a history of compression of the left cranial nerve XI (spinal accessory nerve) from an old sports injury. Based on this information, what technique does the nurse include in the focused assessment?
a. Asking the patient to rotate the head against resistance of the nurses hand on the patients chin
b. Asking the patient to flex the chin to the chest against resistance of the nurses hand on the patients forehead
c. Asking the patient to extend the head back against resistance of the nurses hand on the back of the patient head
d. Asking the patient to shrug the shoulders while the nurse attempts to push them down
ANS: D

Feedback
A The sternocleidomastoid is tested by the patient flexing the chin to the chest while the nurse tries to manually force the head upright.
B The trapezius muscle is tested by the patient shrugging the shoulders while the nurse attempts to push them down.
C The deltoid muscle is tested by the patient holding the arms up while the nurse tries to push them down.
D The pectoralis major muscle is palpated for tenderness, but its strength is not usually assessed.
DIF: Cognitive Level: Understand REF: 314
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

16. When a nurse asks a patient to place the right arm behind the back, so that the back of the hand is touching the lower spine, the nurse is testing for which range of motion?
a. Pronation of the elbow
b. Hyperextension of the elbow
c. Internal rotation and adduction of the shoulder
d. External rotation and abduction of the shoulder
ANS: C

Feedback
A Pronation of the elbow is tested by pronating the palm on a flat surface.
B Hyperextension of the elbow. This is not a motion of the elbow.
C Internal rotation and adduction of the shoulder is tested by this maneuver.
D External rotation and abduction of the shoulder is tested by asking the patient to place the hand behind the head.
DIF: Cognitive Level: Apply REF: 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

17. When a nurse asks a patient to place the right arm behind the head, the nurse is testing for which range of motion?
a. Flexion of the elbow
b. Hyperextension of the shoulder
c. Internal rotation and adduction of the shoulder
d. External rotation and abduction of the shoulder
ANS: D

Feedback
A Flexion of the elbow requires the patient to flex the elbow, but the elbow flexion is usually tested by asking the patient to bend the elbow so that the fingers are touching the shoulder.
B Hyperextension of the shoulder is tested by moving the arm straight backward.
C Internal rotation and adduction of the shoulder is tested by asking the patient to place the hand behind the back.
D External rotation and abduction of the shoulder is tested by this maneuver.
DIF: Cognitive Level: Apply REF: 315
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

18. The nurse asks the patient to rest the left arm on a table and to move the lower arm so that the palm of the hand is up and then down. What motion is the nurse testing?
a. Adduction and abduction of the wrist
b. Supination and pronation of the wrist
c. Adduction and abduction of the elbow
d. Supination and pronation of the elbow
ANS: D

Feedback
A The movements of the wrist are flexion, extension, and ulnar and radial deviation.
B The movements of the wrist are flexion, extension, and ulnar and radial deviation.
C This is not a movement of the elbow. The elbow moves in flexion, extension, pronation, and supination.
D Supination and pronation of the elbow is tested by this maneuver.
DIF: Cognitive Level: Apply REF: 316-317
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

20. With the patient lying supine, a nurse raises the patients leg to flex the hip. The patient complains of pain when the leg is raised to 40 degrees. The nurse correlates this finding with which disorder?
a. Lumbar nerve compression
b. Cervical disk herniation
c. Osteoarthritis
d. Bursitis
ANS: A

Feedback
A To evaluate for nerve root irritation or lumbar disk herniation, perform straight leg raises. Pain in the back of the leg with 30 to 60 degrees of elevation indicates pressure on a lumbar peripheral nerve by an intervertebral disk.
B Straight leg raises evaluate for herniated disks, but not in the cervical disks in the neck.
C Osteoarthritis is a degenerative disease of articular cartilage that affects weight-bearing joints such as vertebrae, hips, knees, and ankles. Straight leg raises is not a technique to assess for osteoarthritis.
D Bursa become inflamed by constant friction around joints and may be precipitated by arthritis or injury. The hip is a common site, but not vertebrae. Manifestations include painful range of motion, point tenderness, and erythema of the affected joint.
DIF: Cognitive Level: Apply REF: 329| 333
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

21. With the patient in a supine position, how does a nurse test the external rotation of the patients right hip?
a. Asking the patient to move the right leg laterally with the right knee straight
b. Asking the patient to flex the right knee and turn medially toward the left side (inward)
c. Asking the patient to place the right heel on the left patella
d. Asking the patient to raise the right leg straight up and perpendicular to the body
ANS: C

Feedback
A Moving the right leg laterally with the right knee straight assesses abduction of the right hip.
B Flexing the right knee and turning medially toward the left side (inward) internally rotates the right hip.
C Placing the right heel on the left patella externally rotates the right hip.
D Raising the right leg straight up and perpendicular to the body flexes the right hip.
DIF: Cognitive Level: Apply REF: 320-321
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

22. What movement from the patient does a nurse request to assess for hyperextension of the hip?
a. Raise one leg at a time while lying prone.
b. Raise one leg at a time while lying supine.
c. Move one leg at a time laterally, away from midline, while lying prone.
d. Move one leg at a time medially, toward midline, while lying supine.
ANS: A

23. How does a nurse assess the eversion and inversion of a patients ankle?
a. For eversion, ask the patient to turn the sole of the foot away from the body and for inversion turn the sole of the foot toward the midline.
b. For eversion, ask the patient to turn the sole of the inward toward the midline and for inversion turn the sole of the foot away from the body.
c. For eversion, ask the patient to walk on his toes and, for inversion, to walk on his heels.
d. For eversion, ask the patient to point the toes forward and, for inversion, to point the toes backward.
ANS: A

Feedback
A This is the correct maneuver for eversion and inversion of the ankle.
B This movement is the opposite of the correct movement.
C This is the test for muscle strength of the ankles and feet.
D This is the maneuver for dorsiflexion and plantar flexion of the ankle.
DIF: Cognitive Level: Apply REF: 324-325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

24. While giving a history, the patient reports having carpal tunnel syndrome. Based on this information, what technique does the nurse include in a focused assessment?
a. Ask the patient to press the pads of the right and left fingers against each other and hold for 1 minute.
b. Ask the patient to push the hand against the nurses forearm while attempting to flex the wrist.
c. Ask the patient to flex both wrists and press the dorsal aspects of the hands together for 1 minute.
d. Hold pressure to the radial and ulnar pulses and watch for blanching.
ANS: C

Feedback
A This is not the correct technique for Phalen sign.
B This is not the correct technique for Phalen sign.
C This is the correct technique for Phalen sign.
D This is the technique for Allens test, which is used to detect arterial circulation of the hand, rather than Phalen sign, which is used to test for carpel tunnel syndrome.
DIF: Cognitive Level: Apply REF: 325
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

25. In teaching the group of patients about osteoporosis, the nurse identifies which one of these participants as having the highest risk for this disease?
a. A small-boned, thin white American woman
b. An American Indian man who smokes
c. A Hispanic woman who has completed menopause
d. An African American man with a family history of osteoporosis
ANS: A

1. Which findings are expected from a musculoskeletal assessment of a left-handed healthy adult? Select all that apply.
a. Cervical concave, thoracic convex, and lumbar concave contours of the spine
b. Muscle strength of 3/5 bilaterally
c. Circumference of left upper arm larger than right upper arm
d. Lumbar and thoracic spine flexion of 75 degrees
e. External rotation and abduction of left arm of 90 degrees
f. Flexion of right and left knees of 90 degrees
ANS: A, C, D, E
Correct: Cervical concave, thoracic convex, and lumbar concave contours of the spine are expected findings of the spine. The circumference of the left upper arm larger than the right upper arm is considered an expected finding because this patient is left-handed, which may account for the increase in circumference. Lumbar and thoracic spine flexion of 75 degrees is an expected finding of the spine. Ninety-degree external rotation and abduction of the left arm is an expected finding of the spine.
Incorrect: The expected muscle strength is 5/5. The expected flexion is 120 degrees.

3. Which movements does a nurse expect to find when assessing the hip range of motion of a healthy person? Select all that apply.
a. Pronation and supination
b. Flexion and extension
c. Internal and external rotation
d. Adduction and abduction
e. Hyperextension
ANS: B, C, D, E
Correct: These are all expected motions for the hip joint.
Incorrect: Pronation and supination are not expected motions for the hip joint.

4. Which movements does a nurse expect to find when assessing the ankle range of motion of a healthy person? Select all that apply.
a. Inversion and eversion
b. Plantar flexion and dorsiflexion
c. Pronation and supination
d. Adduction and abduction
e. Rotation
ANS: A, B, D, E
Correct: These are all expected motions for the ankle joint.
Incorrect: Pronation and supination are not expected motions for the ankle joint.